On Doctoring MEDLINE searches, with reference librarian comments, March 2000

The question was

What are effective treatments for a manic episode of bipolar disorder?

1     Bipolar disorder/pc,dt,rh,su,th [Prevention & Control, Drug    results= 1954   
Therapy, Rehabilitation, Surgery, Therapy]
2     "MANIC EPISODE".mp.    results= 85   
3     (mania or manic or hypermania or hypomania).mp. [mp=title,    results=2184   
abstract, registry number word, mesh subject heading]
4     1 and 3    results= 648   
5     limit 4 to (human and english language)    results= 570   
6     *Bipolar disorder/pc,dt,rh,su,th    results=1070   
7     3 and 6    results= 414   
8     limit 7 to (human and english language)    results=375   
9     limit 8 to yr=1997-2000    results=147   
10     limit 9 to (classical article or clinical conference or    results=131   
clinical trial or clinical trial, phase i or clinical
trial, phase ii or clinical trial, phase iii or clinical
trial, phase iv or congresses or controlled clinical trial
or "corrected and republished article" or guideline or
interview or journal article or lectures or meta analysis
or monograph or multicenter study or news or overall or
practice guideline or published erratum or randomized
controlled trial or retracted publication or retraction of
publication or review or review literature or review of
reported cases or review, academic or review, multicase or
review, tutorial or technical report)

Reference Librarian comments

Good job. You're getting around MEDLINE just fine. It's quite-a-bit a matter of play and experimentation sometimes.

I decided to do this same search, just for fun. See below.

There's an "EBM" review on this, but it didn't look too relevant to me. There are certainly a variety of ways to do this search.

There's also a database called "PsycINFO," the "medline" of the Psyc world, available at:

http://dciswww.dartmouth.edu:50080/?&&&388&s

Medline 1991 to January 2000

#
Search History
Results
1
exp *bipolar disorder/pc,dt,rh,su,th
1071
2
limit 1 to ebm reviews
1
3
limit 1 to meta analysis
4
4
manic episode$.mp.
169
5
1 and 4
56
6
from 5 keep 1-10
10

Results of your search (set 5): 1 and 4
Citations available: 56
Citations displayed: 1-10

<1>
AN 99331601
AU Soutullo CA. Sorter MT. Foster KD. McElroy SL. Keck PE.
IN Division of Child and Adolescent Psychiatry, Children's Hospital Medical
Center, Cincinnati, OH, USA.
TI Olanzapine in the treatment of adolescent acute mania: a report of seven
cases.
SO Journal of Affective Disorders. 53(3):279-83, 1999 Jun.
LM Not at Dartmouth/DHMClibraries;request on interlibrary loan.
AB BACKGROUND: Clozapine may be effective in adults and adolescents with
treatment-resistant bipolar disorder.
Olanzapine has a receptor affinity profile similar to that of clozapine.
METHODS: The responses of seven consecutive adolescents (ages 12-17) with
DSM-IV bipolar disorder,
manic episode, treated with olanzapine were
evaluated. Response to olanzapine was rated as marked, moderate, minimal,
none or worse. RESULTS: Five (71%) adolescents showed a marked or moderate
response. The mean+/-SD olanzapine dose was 0.146+/-0.086 mg/kg/day (11+/-6
mg/day). CONCLUSION: Olanzapine may have antimanic effects
in some adolescents with acute mania. Controlled studies of olanzapine in
adolescent bipolar disorder appear to be
warranted.

<2>
AN 99331595
AU Kessing LV.
IN Department of Psychiatry, University of Copenhagen, Rigshospitalet, Denmark.
lars.kessing@dadlnet.dk
TI The effect of the first manic episode in
affective disorder: a case register study of hospitalised
episodes.
SO Journal of Affective Disorders. 53(3):233-9, 1999 Jun.
LM Not at Dartmouth/DHMClibraries;request on interlibrary loan.
AB BACKGROUND: It is poorly understood how the course of illness in depressive
patients is affected by a manic episode.
METHOD: The course of hospitalised episodes was compared for
patients with depressive episodes only, patients who
presented with a manic or circular first
episode and patients who presented with a depressive first
episode and later developed mania. The Danish psychiatric
central register was used as a study base, including all hospital admissions
with primary affective disorder in Denmark during 1971-1993.
RESULTS: A total of 17,447 patients presented with a depressive first
episode and 2903 patients with a manic or
circular first episode. Among the 17,447 depressive
patients, 762 patients presented with mania at later
episodes (4.4%). Younger age at onset was associated with
increased risk of developing mania. Patients who had a late first
manic episode had the same rate of
subsequent recurrence as patients with mania at first
episode and this rate was higher than the rate of recurrence
for patients who remained having depressive episodes only.
Time since first manic episode was without
importance in relation to the risk of subsequent recurrence. CONCLUSION:
Patients who present with depression and later develop mania have from onset
the same risk of recurrence as initially bipolar patients.
LIMITATION: The data relate to admissions rather than
episodes. CLINICAL RELEVANCE: Younger patients who present
with depression have increased risk of developing bipolar
disorder.

<3>
AN 99422530
AU Kramer BA.
IN Department of Psychiatry and the Behavioral Sciences, University of Southern
California School of Medicine, Los Angeles, USA.
TI A seasonal schedule for maintenance ECT.
SO Journal of Ect. 15(3):226-31, 1999 Sep.
LM Dana Biomedical Library (Dana).
AB The case of a patient with bipolar
disorder is presented to illustrate that past clinical
course may suggest flexible scheduling strategies for maintenance ECT (MECT),
which will allow some patients to be successfully treated with the fewest
number of ECT. For 7 years prior to MECT, manic
episodes regularly occurred during early summer and late
autumn/early winter. ECT rapidly aborted the mania in the two
episodes prior to referral for MECT. Given the rhythmicity
of his manic episodes, MECT was begun by
giving four outpatient ECT during the two at-risk periods each year to both
abort and prevent affective episodes and to stop cycling. No
breakthrough hypomania occurred by the third such period, and the ECT was
reduced to three ECT for the following period and two for the next. The
patient had no significant affective episodes or
hospitalizations during the 3 years of MECT. He continued maintenance lithium
carbonate between ECT. This treatment strategy has allowed the patient to
maintain stability in his employment and personal life.

<4>
AN 99413656
AU Goldstein TR. Frye MA. Denicoff KD. Smith-Jackson E. Leverich GS. Bryan
AL. Ali SO. Post RM.
IN Department of Clinical Psychology, University of Colorado, Boulder, USA.
TI Antidepressant discontinuation-related mania: critical prospective
observation and theoretical implications in bipolar
disorder.
SO Journal of Clinical Psychiatry. 60(8):563-7; quiz 568-9, 1999 Aug.
LM Pre-1993 at Dana,1993-date at MFHSL.
AB BACKGROUND: Development of manic symptoms on antidepressant
discontinuation has primarily been reported in unipolar patients. This case
series presents preliminary evidence for a similar phenomenon in
bipolar patients. METHOD: Prospectively obtained life chart
ratings of 73 bipolar patients at the National Institute of
Mental Health were reviewed for manic
episodes that emerged during antidepressant taper or
discontinuation. Medical records were utilized as a corroborative resource.
Six cases of antidepressant discontinuation-related mania were identified and
critically evaluated. RESULTS: All patients were taking conventional mood
stabilizers. The patients were on antidepressant treatment a mean of 6.5
months prior to taper, which lasted an average of 20 days (range, 1-43 days).
First manic symptoms emerged, on average, 2 weeks into the
taper (range, 1-23 days). These 6 cases of antidepressant
discontinuation-related mania involved 3 selective serotonin reuptake
inhibitors (SSRIs), 2 tricyclic antidepressants (TCAs), and 1
serotonin-norepinephrine reuptake inhibitor. Mean length of the ensuing
manic episode was 27.8 days (range, 12-49
days). Potential confounds such as antidepressant induction, phenomenological
misdiagnosis of agitated depression, physiologic drug withdrawal syndrome,
and course of illness were carefully evaluated and determined to be
noncontributory. CONCLUSION: These 6 cases suggest a paradoxical effect
whereby antidepressant discontinuation actually induces mania in spite of
adequate concomitant mood-stabilizing treatment. These preliminary
observations, if replicated in larger and controlled prospective studies,
suggest the need for further consideration of the potential biochemical
mechanisms involved so that new preventive treatment approaches can be
assessed.

<5>
AN 99313955
AU Burt T. Sachs GS. Demopulos C.
IN Department of Psychiatry, Massachusetts General Hospital, Harvard Medical
School, USA.
TI Donepezil in treatment-resistant bipolar
disorder.
SO Biological Psychiatry. 45(8):959-64, 1999 Apr 15.
LM Pre-1993 at Dana,1993-date at MFHSL.
AB BACKGROUND: A considerable percentage of patients with
bipolar disorder do not respond or do not
tolerate conventional treatment. Cholinesterase (ChE) inhibitors have been
suggested to possess depressogenic and antimanic properties.
METHODS: We report a case series of treatment-resistant
bipolar patients (n = 11) to whom we administered the ChE
inhibitor donepezil. Four patients met criteria for current
manic episode, 5 for mixed
episode, 1 for hypomanic
episode, and 1 for major depressive
episode. Donepezil was added to current medication on an
openlabel basis. Ratings were based on a retrospective chart review. RESULTS:
Of the 11 patients, 6 (54.5%) demonstrated marked improvement (improvement in
CGI-S > or = 2), 3 (27.2%) demonstrated slight improvement, 1 did not
respond, and 1 did not tolerate the medication. Among those patients who had
marked improvement (i.e., responders, n = 6), improvement was observed within
2 weeks or less in 5 of them (83%). Patients experienced only minor side
effects. CONCLUSIONS: These pilot data suggest the efficacy and safety of
donepezil in the treatment of bipolar
disorder. To our knowledge this is the first published
report on the use of donepezil in the treatment of mood
disorders. Controlled, randomized, double-blind studies are
necessary to validate these preliminary observations.

<6>
AN 99206623
AU Tohen M. Grundy S.
IN Harvard Medical School, McLean Hospital, Boston, Mass., USA.
TI Management of acute mania. [Review] [39 refs]
SO Journal of Clinical Psychiatry. 60 Suppl 5:31-4; discussion 35-6, 1999.
LM Pre-1993 at Dana,1993-date at MFHSL.
AB Bipolar disorder is a lifelong episodic
condition characterized by mood swings between mania and depression. In the
United States alone, approximately 4 million people are affected by this
disorder. Pharmacologic treatment for acute
manic episodes or as maintenance therapy
includes lithium, valproate, carbamazepine, and typical antipsychotics.
However, many patients fail to respond to these treatments due to lack of
efficacy or production of side effects leading to patient noncompliance.
Non-compliance with pharmacologic treatment is indeed a major risk factor in
bipolar disorder patients and needs to be
managed with ongoing education, psychotherapy, and a simplified but effective
pharmacologic treatment regimen. Recently introduced novel antipsychotics
show much promise as mood-stabilizing agents in bipolar
patients, with minimal risk of treatment-emergent extrapyramidal symptoms and
tardive dyskinesia. Nonetheless, further research is warranted to help
clarify the role of novel antipsychotics in the treatment of
bipolar disorder. [References: 39]

<7>
AN 98453526
AU Brandt C. Grunze H. Normann C. Walden J.
IN Department of Psychiatry, University of Freiburg and University of Munich,
Germany.
TI Acetazolamide in the treatment of acute mania. A case report.
SO Neuropsychobiology. 38(3):202-3, 1998 Oct.
LM Not at Dartmouth/DHMClibraries;request on interlibrary loan.
AB Several antiepileptic drugs are also being used in affective
disorders. There are some hints that also the carbonic
anhydrase inhibitor acetazolamide might be useful in the treatment of
bipolar affective disorder. We report a
39-year-old male patient with a history of bipolar affective
disorder who presented with his second
manic episode. Acetazolamide was added to a
low dose of valproic acid and to perazine. A marked decrease of the BRMAS
score was achieved. The implications of this case are discussed.

<8>
AN 99076211
AU Moll GH. Rothenberger A.
IN Klinik und Poliklinik fur Kinder- und Jugendpsychiatrie,
Georg-August-Universitat, Gottingen.
TI [Lithium salts in child and adolescent psychiatry]. [Review] [20 refs]
[German]
SO Nervenarzt. 69(11):935-43, 1998 Nov.
LM Not at Dartmouth/DHMClibraries;request on interlibrary loan.
AB Lithium is--besides neuroleptics--the drug of choice for the treatment of
manic episodes. If the use of
antidepressive drugs, during unipolar depressive illness, does not lead to a
positive response, the additional administration of lithium is appropriate,
even during a depressive episode. Lithium is also considered
as the drug of choice for prophylactic treatment of bipolar
affective disorders. This holds true also for adolescents.
In contrast to the indications in adults, in adolescents an early
administration is desirable to reduce risk factors of psychosocial
development. Additional indications may be the presence of severe
aggressivity in conduct disordered children. In these cases,
a treatment with lithium salts can result in a behavioral improvement. This
may be also the case in impulsive self-injurious behavior. The dosage and
serum levels of lithium, as well as its adverse effects are comparable with
those known from adults. At present, lithium treatment cannot be recommended
for children under 12 years of age--except under in-patient conditions.
[References: 20]

<9>
AN 97159057
AU Swann AC. Bowden CL. Morris D. Calabrese JR. Petty F. Small J.
Dilsaver SC. Davis JM.
IN Department of Psychiatry, University of Texas Medical School at Houston,
USA.
TI Depression during mania. Treatment response to lithium or divalproex [see
comments].
CM Comment in: Arch Gen Psychiatry 1998 Nov;55(11):1050
SO Archives of General Psychiatry. 54(1):37-42, 1997 Jan.
LM Pre-1993 Dana; 1993-dateMFHSL;for Web access-check catalog
AB BACKGROUND: Little information exists from controlled studies about clinical
characteristics that predict treatment response in mania. The presence of
depressive symptoms during manic episodes
may be associated with poor response to psychopharmacological treatments.
This is an investigation of the relation between depressive symptoms and
treatment response in acute manic episodes.
METHODS AND DESIGN: In a parallel-group, double-blind study, 179 patients
hospitalized for acute manic episodes were
randomized to receive divalproex sodium, lithium carbonate, or placebo
(ratio, 2:1:2). The study was carried out at 9 academic medical centers.
Patients had comprehensive evaluations of behavior and symptoms before and
during 3 weeks of treatment. The primary outcome measure, change in mania
factor scores derived from the Schedule for Affective
Disorders and Schizophrenia: Change Version, was compared in
patients with and without depressive symptoms at baseline according to nurse-
or physician-rated scales. RESULTS: Depressive symptoms were associated with
poor antimanic response to lithium and with better response
to divalproex. This was not due to differences in overall severity of
illness, substance abuse, gender, age, or history. CONCLUSIONS: These data
suggest that even a modest level of pretreatment depression-related symptoms
is a robust predictor of lithium nonresponse, and is associated with better
response to divalproex. Although their overall efficacy in acute mania is
similar, lithium and divalproex may be most effective in clinically and
biologically distinct groups of patients.

<10>
AN 99005632
AU Erfurth A. Kammerer C. Grunze H. Normann C. Walden J.
IN Dept. of Psychiatry, LMU University Hospital, Munchen, Germany.
TI An open label study of gabapentin in the treatment of acute mania.
SO Journal of Psychiatric Research. 32(5):261-4, 1998 Sep-Oct.
LM Pre-1993 at Dana,1993-date at MFHSL.
AB Recent anecdotal single case reports have suggested that the new
antiepileptic drug gabapentin might be effective in the treatment of
manic episodes and in the prophylaxis of
bipolar disorder. In the present open
trial, 14 patients with acute mania were treated for up to 21 days with
gabapentin in a dose range from 1200 to 4800 mg/day. Six patients were
treated with gabapentin as add-on medication and 8 patients were treated with
a high dose of gabapentin alone. Gabapentin was both efficacious and safe
when applied in combination with other drugs such as lithium and valproic
acid. All patients in the add-on group and 4/8 patients on gabapentin
monotherapy finished the 21 day protocol. Analysis of the scores of the
Bech-Rafaelsen Mania Assessment Scale (BRMAS) of these patients showed that
the mean BRMAS score declined from 37.7 to 7.8 on day 21 in the add-on group
and from 27.8 to 9.0 in 4/8 patients finishing 21 days in the monotherapy
group. It is suggested that gabapentin monotherapy might be useful in
selected patients to treat modest but not severe manic
states. In addition, gabapentin in conjunction with other effective mood
stabilisers seems to be safe and efficacious in the treatment of severe
mania.